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Doing the EMS Three-Step
You are working an elderly COPDer who has reluctantly agreed to go to the hospital with you, but only after two DuoNeb breathing treatments fail to provide any relief whatsoever. The bottom line remains: Your patient just cannot "catch his breath." That answer comes out in THREE ONE-WORD BURSTS…never a good sign from patients in respiratory distress.
With the transport decision made, now comes the question of how to get him on the cot. You briefly confer with your partner and decide that the best choice is what I call the EMS three-step: stand, pivot and sit. This is arguably one of the most commonly utilized patient maneuvers in all of prehospital care. It is conceptually simple to describe, and, in truth, equally simple to perform under ideal circumstances and when all goes as planned. It is with the latter two—circumstances and plan—where the greatest likelihood of problems lies.
To best limit both the frequency of problems and their severity, it is essential to run through a quick mental checklist and to discuss the plan with your partner. Let's take a look at what's on the list.
Can we safely make this move?
When it's all said and done, this is the money question. If you don't think that you, your partner and your patient can pull off the EMS three-step, for whatever reason, don't even try it. Either get additional resources to assist with the move, or come up with another plan to safely move the patient. Trial and error is not the model to use here.
Does the patient's mental status assure that he understands the plan?
Clearly, a major element in making this move work is that the patient must understand two things: exactly what you are going to do and how quickly or slowly you are going to do it. Once again, it is the latter of the two where the biggest potential problem lies. The patient may well grasp the three pieces of the event, but if it unfolds faster than he anticipated, bad things are on the horizon. If the patient is expecting to slowly rise and turn, but instead you snatch him out of the chair, suddenly bringing him to his feet while simultaneously pivoting him around towards the cot, the chance of the patient losing his balance and stumbling during the move increases markedly. Worse yet, he may fall, potentially flipping the gurney and taking you and your partner along with it.
The next time your gurney is in the upright ready-to-load position, close your eyes and imagine it flipped on its side with you, your partner and your patient wrapped around, over or tangled inside the gurney structure. Not a pretty picture.
Are the patient's legs at least at a 90° angle?
Irrespective of whether the patient is sitting on a couch, chair or even the side of the bed, as long as the angle of the patient's legs are close to 90°, it will take considerably less strength on the patient's part than when the buttocks are lower and that angle is decreased. The lower the buttocks and the smaller the angle, the more difficult the move becomes for the patient and the more lifting it requires by the EMS team.
What if the patient becomes dead weight?
There's a world of difference between helping the older gentleman in our scenario to his feet (guiding him up and steadying him as he mostly stands by himself) to lifting 175 pounds of sagging dead weight. When a dead weight scenario occurs, it bodes ill for all involved. There is a real possibility of worsening the patient's outcome, and it certainly increases the likelihood that one or both members of the EMS team will sustain injuries.
What is Plan B if the "dead weight" scenario occurs?
Make absolutely sure you discuss this with your partner before you attempt the patient move. In reality there are only three viable options:
- Continue the upward move and muscle the patient onto the cot.
- Immediately take him back down to the chair, ideally in close to the position found.
- Take him down to the chair and continue to slide him down to the floor.
With option #1, it's a combination of patient weight and the sheer muscle power of the team if you are going to pull this off. Even if the weight can be managed, to get the patient up on the gurney, good body mechanics will almost always be compromised. By comparison, option #2 is the safest. Control the descent and put them back where they started. If it becomes apparent that the patient has arrested, option #3 becomes the best choice. With this option, you are looking at a two-stage event: back down to the chair, then a repositioning of hands so you can safely transfer the patient to the floor where CPR can be initiated.
The EMS three-step is a safe, functional move that must be mastered by anyone expecting to work in the prehospital setting. Run through the checklist, talk through the plan, be prepared for the worst, and you'll find that you take better care of your patient and your back.
Until next month…
Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.
